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File Review v. Treating Physician: D. Mass.

10-22-2018, 04:29 PM

In a recent case from Massachusetts, the court expresses concern over the Defendant's decision to weigh its reviewing physicians' opinions seemingly far greater than those of the Plaintiff's actual treating physicians.

What concerns the court in this case is the appearance that Prudential gave conclusive weight to Dr. Fiano’s opinions based on her file review without giving any substantive consideration to the records and opinions of Ampe’s treating physician (Dr. Hermann) and the doctors who had examined Ampe to evaluate his neuropsychological symptoms (Dr. Khumbani, Dr. Berkowitz, and Dr. Bekken). In its final denial letter, Prudential made several conclusory statements that appear unanchored in the medical records. Prudential, for example, criticized Dr. Bekken’s validity testing despite her careful explanation of why the testing convinced her that Ampe was not malingering. The observation that “[t]his single measure [sic] was also noted as insufficient given prior changes in scores Mr. Ampe had shown on previous testing, which had revealed declined scores from his 2015 evaluation arranged by the [SSA], when compared to the first evaluation in 2012,” can fairly be read to say the opposite of what Prudential presumably meant. The reference to somatization is also troubling. Somatization (also known as Briquet’s syndrome) is a discredited clinical diagnosis, derived from the theory that acute anxiety or stress can precipitate real or, more often, imagined physical symptoms in a patient. The reference to somatization underscores the extent to which Prudential’s decision relied on Dr. Fiano’s personal skepticism regarding the validity of any diagnosis of post-concussion syndrome, and on her apparent, if not overtly stated, conviction that Ampe was a malingerer. While the court is not in a position to address in any definitive fashion the medical validity of post-concussion syndrome as a diagnosis, there is enough support in the medical literature documenting its existence so as to make a denial of LTD benefits based on one skeptical doctor’s file review open to question, especially where three examining specialists and a treating physician at different times came to a contrary conclusion.

Additionally, the court was concerned with the Defendant's failure to accurately analyze the Plaintiff's limitations against the demands of his actual occupation.

A second, and perhaps more critical deficiency in Prudential’s benefit denial was its failure to analyze Ampe’s conceded limitations against the demands of his occupation as an electrical engineer. A benefits determination is not “‘reasoned’ when the [claims] administrator sidesteps the central inquiry . . . [of] whether the claimant [is] . . . able to perform the material duties of [his] own occupation.” McDonough v. Aetna Life Ins. Co., 783 F.3d 374, 380 (1st Cir. 2015). Plan administrators may not dismiss evidence merely because it is subjective, but must meaningfully address why reported symptoms either false or exaggerated or do not impede a claimant’s ability to work. Miles v. Principal Life Ins. Co., 720 F.3d 472, 487 (2d Cir. 2013); see also Love v. Nat'l City Corp. Welfare Benefits Plan, 574 F.3d 392, 396 (7th Cir.2009) (finding that defendant failed to sufficiently explain the reasons for its denial of disability benefits as required by 29 U.S.C. § 1133, where “neither the initial termination letter nor the subsequent letter denying [the claimant's] appeal explained why the reviewer chose to discredit the evaluations and conclusions of [the claimant's] treating physicians”) (emphasis in original). In this context, Prudential failed to meaningfully address and properly weigh Ampe’s complaints of severe headaches and fatigue. (Dr. Fiano specifically disclaimed any consideration of these complaints as lying outside her area of expertise). As underscored by Judge Selya in McDonough v. Aetna Life Ins. Co., 783 F.3d 374, 380 (1st Cir. 2015), “medical evidence is only part of the equation. To assess a claimant’s ability to perform his own occupation, a decisionmaker must be aware of, and apply, the requirements of the occupation.” Here, there is no record evidence that Prudential (unlike the SSA) engaged in an analysis of the impact of Ampe’s limitations, whether subjective or substantiated by the clinical examinations and objective testing, on his ability to perform the work of a Senior Development and Test Engineer.9 See Miller v. Am. Airlines, Inc., 632 F.3d 837, 854 (3d Cir. 2010) (citing Elliot v. Metro. Life Ins. Co., 473 F.3d 613, 619 (6th Cir. 2006) (finding a decision could not be considered “reasoned” where there was no discussion of claimant’s duties or her ability to complete them in light of the various diagnoses).

Ultimately, the court remanded the case for consideration. The full opinion is attached.